Epicardial access for ventricular tachycardia and premature ventricular complexes ablation: An institutional experience

BACKGROUND Epicardial access for ventricular arrhythmia (VA) ablation is a challenging and relatively uncommon procedure during ventricular ablation. OBJECTIVE This study aimed to assess the outcomes, predictors of success, and complications associated with pericardial access during these procedures. METHODS This multicenter, retrospective, observational study included data collected over 20 years (2004-2024) from all Mayo Clinic sites performing VA ablation with epicardial access. RESULTS A total of 265 patients were included in the analysis: 196 for VT ablation and 69 for PVC ablation. Among them, 184 (69%) had at least 1 previous VA ablation, 51 (19.2%) had ischemic cardiomyopathy, 53 (20%) had structurally normal hearts, and 164 (61.9%) had nonischemic cardiomyopathies (NICMs). Three presented with concomitant ischemic cardiomyopathy and NICM. Within the NICM group, the most common diagnoses were dilated cardiomyopathy (n = 80 [30.2%]), arrhythmogenic right ventricular cardiomyopathy (n = 34 [12.8%]), and sarcoidosis (n = 15 [5.7%]). Acute success, defined as noninducibility, was achieved in 100 (61.7%) of 162 patients tested, while partial success (clinical arrhythmia noninduciblility) was observed in 47 (29%). Before discharge, VT recurred in 20 patients (10.2%). During a median follow-up of 61 months, events were observed as follows: 60 (35.5%) patients died, 26 (13.3%) underwent heart transplantation, and 62 (31.6%) required a repeat ablation for VAs. The event-free survival rates were 50% (95% confidence interval 43%-58%) at 1 year. CONCLUSION Successful VT ablation with epicardial access can be achieved in select cases, though event-free survival remains suboptimal. Advanced disease stage and persistent inducibility at the end of the procedure are predictors of poor outcomes.